Nurse Specialist II

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct reviews of medical records and claims for Medicare, Medicaid, and/or other claims data

• Ensure adherence to established guidelines

• Evaluate potential overpayments, fraud, waste, and abuse

• Examine cases involving beneficiaries, providers, and/or pharmacies

• Carry out desk reviews or field audits

• Collaborate with experts in benefit integrity investigations and pharmacists

• Prepare case summaries and present findings to investigators

• Execute case-specific or plan-specific data entry and reporting

• Engage in internal and external focus groups

• Participate in onsite visits to providers and interviews with beneficiaries for field audits/investigations

• Provide testimony at legal proceedings when necessary

• Facilitate job-specific orientation and training

• Assist in the development of training content, resources, and programs

⛳️ Requirements

• A minimum of a Bachelor's Degree is required

• 2 - 4 years of relevant experience is mandatory

• 5 - 7 years of experience is preferred

• Experience in medical review is preferred

• Current, active, and unrestricted RN licensure is required

• Coding certification is preferred

• Successful completion of pre-employment background checks and drug screenings is required

🏝️ Benefits

• Equal Opportunity Employer for Minorities, Females, Protected Veterans, and Individuals with Disabilities

• Drug-free workplace

• Offers contingent upon successful completion of pre-employment background checks and drug screenings